Forearm Fracture Management in the ED Clinical Presentation

Updated: Feb 04, 2022
  • Author: Toluwumi Jegede, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Presentation

Physical

Patients usually have localized pain, tenderness, and swelling at the fracture site. Fractures are classified as open or closed. Consider any puncture or break in the skin over a fracture site evidence of an open fracture unless proven otherwise. Infection is commonly seen with open fractures and warrants emergent orthopedic evaluation. The incidence of open forearm fractures is second only to that of the tibia.

History is usually consistent with a direct blow to the forearm or a fall directly onto the forearm or outstretched hand. Understanding the mechanism of injury helps direct the physical examination to detect injuries.

The Gustilo open fracture classification system [13, 14]  has significant interuser variability; the extent of the wound often cannot be determined until intraoperative exploration is performed. Forearm fractures are classified as follows [15] :

  • Type I: Puncture wound less than 1 cm; minimal contamination; minimal soft tissue damage

  • Type II: Laceration greater than 1 cm but less than 10 cm; moderate soft tissue damage; adequate bone coverage

  • Type IIIA: Laceration greater than 10 cm; extensive soft tissue damage; massive contamination; adequate bone coverage

  • Type IIIB: Laceration greater than 10 cm; extensive soft tissue damage; massive contamination; periosteal stripping and bone exposure

  • Type IIIC: Arterial injury requiring repair

Perform a neurologic examination. Evaluate sensory function by 2-point discrimination. Assess motor function by having the patient make the following maneuvers: "OK" sign tests the median nerve, extending the fingers or wrist against resistance tests the radial nerve, and separating the fingers against resistance tests the ulnar nerve.

Tendons or muscle bellies entrapped in fracture fragments may account for unusual functional deficits.

Perform a vascular examination. Check capillary refill and radial pulse, and perform the Allen test.

Examine the wrist and elbow for tenderness and range of motion. Palpate the wrist to evaluate for ulnar styloid fracture, dorsal prominence of the ulna, or wrist pain with rotation.Tenderness or prominence of the radial head may be the only physical finding in patients with reduced Monteggia lesion or radial head fracture.